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<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% select_tag name=&quot;833391fc&quot; data_label=&quot;Aanhef&quot; data_map_field=&quot;civilite&quot; data_help=&quot;Kies de aanhef&quot; data_choices=&quot;Aanhef|civilite; Meneer|monsieur; Mevrouw|madame;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><strong>&nbsp;</strong>Achternaam :</span></td>
			<td style="vertical-align: bottom; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Voornaam :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;087a9c2a&quot; data_label=&quot;Achternaam van de ondertekenaar&quot; data_map_field=&quot;nom&quot; data_help=&quot;Achternaam van de ondertekenaar, geef de meisjesnaam op indien van toepassing&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;002cb93f&quot; data_label=&quot;Voornaam van de ondertekenaar&quot; data_map_field=&quot;prenom&quot; data_help=&quot;Voornaam van de ondertekenaar&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 70%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">E-mail :&nbsp;</span></td>
			<td style="vertical-align: middle; width: 30%;">&nbsp;<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Tel :&nbsp;&nbsp;</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;7a4b4c6f&quot; data_label=&quot;E-mail van de ondertekenaar&quot; data_map_field=&quot;email&quot; data_help=&quot;E-mail van de ondertekenaar&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 30%;">{% textinput_tag name=&quot;ed7c9998&quot; data_label=&quot;Telefoon van de ondertekenaar&quot; data_map_field=&quot;tel&quot; data_help=&quot;Telefoon van de ondertekenaar&quot; maxlength=&quot;25&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Geboortedatum :</span></td>
			<td style="vertical-align: middle; width: 80%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Geboorteplaats :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 20%;">{% dateinput_tag name=&quot;f014d7d1&quot; placeholder=&quot;dd/mm/jjjj&quot; data_label=&quot;Geboortedatum&quot; data_map_field=&quot;date_naissance&quot; data_help=&quot;Geboortedatum&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}</td>
			<td style="vertical-align: middle; width: 80%;">{% textinput_tag name=&quot;67fe78de&quot; data_label=&quot;Geboorteplaats&quot; data_map_field=&quot;lieu_naissance&quot; data_help=&quot;Geboorteplaats&quot; maxlength=&quot;80&quot; data_ancien_ids=&quot;21911&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Beroep :</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nationaliteit :</span></td>
		</tr>
		<tr>
			<td>{% textinput_tag name=&quot;14a7a8af&quot; data_label=&quot;Beroep&quot; data_map_field=&quot;job&quot; data_help=&quot;Beroep&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td>{% textinput_tag name=&quot;732abf19&quot; data_label=&quot;Nationaliteit&quot; data_map_field=&quot;nationality&quot; data_help=&quot;Nationaliteit&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 68%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Adres :</span></td>
		</tr>
		<tr>
			<td style="width: 68%;">{% textinput_tag name=&quot;109d7745&quot; data_label=&quot;Postadres van de ondertekenaar&quot; data_map_field=&quot;adresse&quot; data_help=&quot;Postadres van de ondertekenaar&quot; maxlength=&quot;100&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Postcode :</span></td>
			<td style="width: 55%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Stad :</span></td>
			<td style="width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Land :</span></td>
		</tr>
		<tr>
			<td style="width: 20%;">{% textinput_tag name=&quot;f5e66571&quot; data_label=&quot;Postcode van de ondertekenaar&quot; data_map_field=&quot;zipcode&quot; data_help=&quot;Postcode van de ondertekenaar&quot; maxlength=&quot;10&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 55%;">{% textinput_tag name=&quot;ed0a66fe&quot; data_label=&quot;Stad van de ondertekenaar&quot; data_map_field=&quot;ville&quot; data_help=&quot;Stad van de ondertekenaar&quot; maxlength=&quot;80&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 25%;">{% textinput_tag name=&quot;4e0fc70a&quot; placeholder=&quot;Luxemburg&quot; data_label=&quot;Land van de ondertekenaar&quot; data_map_field=&quot;pays&quot; data_help=&quot;Land van de ondertekenaar&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% select_tag name=&quot;550e32cc&quot; data_label=&quot;Aanhef&quot; data_map_field=&quot;civilite&quot; data_help=&quot;Kies de aanhef&quot; data_choices=&quot;Aanhef|civilite; Meneer|monsieur; Mevrouw|madame;&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;"><strong>&nbsp;</strong>Achternaam :</span></td>
			<td style="vertical-align: bottom; width: 50%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Voornaam :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;3d948d74&quot; data_label=&quot;Achternaam van de ondertekenaar&quot; data_map_field=&quot;nom&quot; data_help=&quot;Achternaam van de ondertekenaar, geef de meisjesnaam op indien van toepassing&quot; maxlength=&quot;50&quot; relation_ids_list=&quot;322861a6&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 50%;">{% textinput_tag name=&quot;6be847fb&quot; data_label=&quot;Voornaam van de ondertekenaar&quot; data_map_field=&quot;prenom&quot; data_help=&quot;Voornaam van de ondertekenaar&quot; maxlength=&quot;50&quot; relation_ids_list=&quot;ac7e9636&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 70%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">E-mail :</span></td>
			<td style="vertical-align: middle; width: 30%;">&nbsp;<span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Tel :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 70%;">{% textinput_tag name=&quot;30cf5700&quot; data_label=&quot;E-mail van de ondertekenaar&quot; data_map_field=&quot;email&quot; data_help=&quot;E-mail van de ondertekenaar&quot; maxlength=&quot;50&quot; relation_ids_list=&quot;627736e1&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="vertical-align: middle; width: 30%;">{% textinput_tag name=&quot;153395a3&quot; data_label=&quot;Telefoonnummer van de ondertekenaar&quot; data_map_field=&quot;tel&quot; data_help=&quot;Telefoonnummer van de ondertekenaar&quot; maxlength=&quot;25&quot; relation_ids_list=&quot;382a5e67&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Geboortedatum :</span></td>
			<td style="vertical-align: middle; width: 80%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Geboorteplaats :</span></td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 20%;">{% dateinput_tag name=&quot;af71a231&quot; placeholder=&quot;dd/mm/jjjj&quot; data_label=&quot;Geboortedatum&quot; data_map_field=&quot;date_naissance&quot; data_help=&quot;Geboortedatum&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;true&quot; %}</td>
			<td style="vertical-align: middle; width: 80%;">{% textinput_tag name=&quot;48b8b7d8&quot; data_label=&quot;Geboorteplaats&quot; data_map_field=&quot;lieu_naissance&quot; data_help=&quot;Geboorteplaats&quot; maxlength=&quot;80&quot; data_ancien_ids=&quot;21911&quot; relation_ids_list=&quot;412d69a0&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Beroep&nbsp;:</span></td>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Nationaliteit&nbsp;:</span></td>
		</tr>
		<tr>
			<td>{% textinput_tag name=&quot;3dbf729e&quot; data_label=&quot;Beroep&quot; data_map_field=&quot;job&quot; data_help=&quot;Beroep&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td>{% textinput_tag name=&quot;28cdc83b&quot; data_label=&quot;Nationaliteit&quot; data_map_field=&quot;nationality&quot; data_help=&quot;Nationaliteit&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2" style="width:100%;">
	<tbody>
		<tr>
			<td style="width: 20%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Postcode :</span></td>
			<td style="width: 55%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Stad :</span></td>
			<td style="width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Land :</span></td>
		</tr>
		<tr>
			<td style="width: 20%;">{% textinput_tag name=&quot;f5e66571&quot; data_label=&quot;Postcode van de ondertekenaar&quot; data_map_field=&quot;zipcode&quot; data_help=&quot;Postcode van de ondertekenaar&quot; maxlength=&quot;10&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 55%;">{% textinput_tag name=&quot;ed0a66fe&quot; data_label=&quot;Stad van de ondertekenaar&quot; data_map_field=&quot;ville&quot; data_help=&quot;Stad van de ondertekenaar&quot; maxlength=&quot;80&quot; relation_ids_list=&quot;12099384&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
			<td style="width: 25%;">{% textinput_tag name=&quot;4e0fc70a&quot; placeholder=&quot;Luxemburg&quot; data_label=&quot;Land van de ondertekenaar&quot; data_map_field=&quot;pays&quot; data_help=&quot;Land van de ondertekenaar&quot; maxlength=&quot;50&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="1" cellspacing="5" style="width:100%;">
	<tbody>
		<tr>
			<td style="vertical-align: middle; width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Datum en plaats van het huwelijk&nbsp;: </span></td>
			<td>{% textinput_tag name=&quot;377a5647&quot; data_label=&quot;Datum en plaats van het huwelijk&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Datum en plaats van het huwelijk&quot; maxlength=&quot;70&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
		<tr>
			<td style="vertical-align: middle; width: 25%;"><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Huwelijksstelsel&nbsp;:</span></td>
			<td>{% textinput_tag name=&quot;f24e2d99&quot; data_label=&quot;Huwelijksstelsel&quot; data_map_field=&quot;nomap&quot; data_help=&quot;Huwelijksstelsel&quot; maxlength=&quot;70&quot; data_required_field=&quot;false&quot; data_bold_text=&quot;false&quot; %}</td>
		</tr>
	</tbody>
</table>

<table border="0" cellpadding="2" cellspacing="2">
	<tbody>
		<tr>
			<td><span style="font-family:ITCAvantGardePro;font-size:12px;font-weight:200;">Optredend als: {% radio_tag name=&quot;a6c38d5e&quot; data_label=&quot;Rol van de ondertekenaar&quot; data_map_field=&quot;nomap&quot; data_choices=&quot;eigenaar(s)&nbsp;&nbsp;&nbsp; |propri&eacute;taire(s); gevolmachtigde(n)&nbsp;&nbsp;&nbsp; |mandataire(s); lasthebber&nbsp;&nbsp;&nbsp; |porte-fort;&quot; %}</span></td>
		</tr>
	</tbody>
</table>

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